Provider Demographics
NPI:1124412366
Name:WATT, GAELEN (DPT)
Entity Type:Individual
Prefix:MR
First Name:GAELEN
Middle Name:
Last Name:WATT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10121 SE SUNNYSIDE RD
Mailing Address - Street 2:#208
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015
Mailing Address - Country:US
Mailing Address - Phone:503-794-0103
Mailing Address - Fax:503-794-0104
Practice Address - Street 1:10121 SE SUNNYSIDE RD
Practice Address - Street 2:#208
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-794-0103
Practice Address - Fax:503-794-0104
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR63280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program